Nurse at Home

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care or notify the physician of missed visits for 2 of 3 sampled patients with missed visits. (Patients #1 and #7) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient’s health care needs. Findings: According to the agency policy, titled Plan of Care, dated 4/13/22, modifications to the care plan are indicted by changes in visit frequencies. These are documented on discipline progress notes or a physician verbal order. Verbal orders will be signed and dated by the physician. During an interview on 2/11/25 at 3:54 PM, Clinical Manager reported the missed visit documentation is faxed to the physician and would be in the fax log in the electronic medical record. 1.Patient #1 had a start of care date of 1/1/21. Clinical record review revealed: a. Plan of Care, dated 12/22/24 to 2/19/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for skilled nurse and home health aide services. b. Missed visit documentation, dated 1/3/25, included documentation patient refused the aide visit and physician was not notified. c. Missed visit documentation, dated 1/24/25, included documentation no answer to phone call for aide visit and physician not notified. Agency failed to notify the physician of missed aide visits. 2. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus and orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Missed visit documentation, dated 8/12/24, 8/23/24, 9/10/24, and 9/13/24, included documentation patient refused the aide visit and physician was not notified c. Missed visit documentation, dated 8/19/24, included documentation of a missed aide visit and physician was not notified. Agency failed to notify the physician of missed aide visits. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on home observations, staff interviews, clinical record review and policy review, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice for 2 of 3 sampled patients (Patient #1 and #3) with home observation visits. Failure to follow accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infections. 2. Patient #1 had a start of care dated of 1/1/21. The surveyor accompanied Staff D, Registered Nurse (RN), to a home visit on 2/10/25 at 1:20 PM. Staff D while applying Vaseline to patient’s lower legs, removed gloves, removed stethoscope from around her neck and placed in nursing bag, pulled hair back into a pony tail, reapplied gloves, and continued to apply Vaseline to patient’s lower legs. Staff D failed to complete hand hygiene after removing gloves and before putting on new gloves and to clean stethoscope prior to returning it to the nursing bag. The agency failed to ensure infection control standards were followed during patient care. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. Findings include: According to the agency policy titled Bag Technique, dated 4/13/22, the nursing bag is placed on a clean surface in the home and following hand hygiene the supplies and or equipment needed for the visit are removed from the bag. When the visit is completed, reusable equipment is cleaned using alcohol disinfectant wipe and or soap/water as appropriate and placed on a clean surface, hands are washed and equipment is returned to the bag. 1.Patient #3 had a start of care date of 2/4/25. Home observation and clinical record review revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25 identified the patient as having primary diagnosis of chromic leukemia and heart failure and physician orders for medications and treatments, with skilled nurse, physical and occupational therapy, and home health aide services. b. During a home observation visit on 2/11/25 at 9:15 AM with Staff F, Registered Nurse (RN), the surveyor observed the RN returning the vital sign equipment back inside her bag without disinfecting the items first. The agency failed to perform bag technique according to agency policy and in accordance with accepted infection control standards of practice”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on home visit observation and admission folder review, the agency failed to provide agency patients with the Administrator name, business address and business phone number. The agency failed to provide this information for 2 of 3 sampled patients with home visits (Patients #2 and #3). Failure to provide the Administrator name and contact information left the patients without the needed information to contact the agency Administrator with any concerns that may have occurred. 2. Patient #3 had a start of care date of 2/4/25. Home Observation and clinical record revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25, included a primary diagnosis of chronic leukemia and heart failure and interim physician orders for skilled nursing, physical therapy and home health aide services. b. During a home observation visit on 2/11/25 at 9:30 AM with Staff F, Registered Nurse (RN), the surveyor reviewed the admission folder in the patient home. The folder failed to provide the agency Administrator name and contact information. The agency failed to provide the agency Administrator name and contact information for the patient. Findings include: 1.Patient #2 had a start of care date of 1/21/25. Clinical record review revealed a Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for skilled nursing, physical therapy and occupational therapy services. During a home visit observation, on 2/11/25 at 10:00 AM, with Staff E, COTA (Certified Occupational Therapy Assistant), the surveyor reviewed the admission folder in the patient home. The folder failed to provide the agency Administrator name and contact information. The agency failed to provide the agency Administrator name and contact information for the patient.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observations, agency staff interview, patient interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment and failed to identify patient specific medication issues for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #5 and #7). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Medication List and Monitoring, dated 4/13/22, the agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient. The Registered Nurse will monitor medications for potential adverse effects and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. Agency nursing staff will assess on an ongoing basis the patient’s response to medication and the patient/caregiver compliance with the medication regimen. 1.Patient #3 had a start of care date of 2/4/25. Clinical record review revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25 identified the patient as having primary diagnosis of chromic leukemia and heart failure and physician orders for medications and treatments, with skilled nurse, physical and occupational therapy, and home health aide services. b. The start of care comprehensive assessment, dated 2/4/25, Staff F, Registered Nurse (RN), included documentation of drug interactions, side effects; but failed to identify duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 2. Patient #4 had a start of care date of 1/8/25. Clinical record review revealed: a. The POC, dated 1/8/25 to 3/8/25, identified the patient as having a diagnosis of hypertension and heart failure, physician orders for medications and treatments, with skilled nurse, physical and occupational therapy services. b. The start of care comprehensive assessment, dated 1/8/25, Staff F, RN, included documentation of drug interactions but failed to identify; side effects, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 3. Patient #5 had a start of care date of 08/22/24. Clinical record review revealed: a. The POC, dated 08/22/24 to 10/20/24, identified the patient as having a diagnosis of type 2 diabetes and Parkinson’s, physician orders for medications and treatments, with skilled nurse, physical and occupational therapy services. b. The start of care comprehensive assessment, dated 8/22/24, Staff G, RN , included documentation of drug interactions and side effects, but failed to identify, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 4. Patient #1 had a start of care date of 1/1/21. Clinical record review revealed: a. Plan of Care, dated 12/22/24 to 2/19/25, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing and home health aide services and medications. b. Recertification comprehensive assessments, dated 8/19/24, 10/21/24 and 12/17/24, included documentation of drug interactions, side effects and duplicate medications; but failed to identify ineffective drug therapy and noncompliance with medications. The RN (registered nurse) failed to identify the required elements of the drug regimen review at the recertification comprehensive assessments. 5. Patient #2 had a start of care date of 1/21/25. Clinical record review revealed: a. Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing, physical therapy and occupational therapy services and medications. b. Start of Care comprehensive assessment, dated 1/21/25, included documentation of drug interactions, but failed to identify side effects, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start pf care comprehensive assessment. 6. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services and medications. b. Start of Care comprehensive assessment, dated 8/9/24, failed to include documentation a drug regimen review had been completed. During an interview on 2/12/25 at 2:38 PM, Clinical Manager reported she had reviewed the clinical record and the comprehensive assessment included documentation under the Medications section, medications reconciled and the question labeled M2001-Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?, was marked as No, No issues found during review. She reported this serves as the drug regimen review and when this question is marked No, the nurse is not able to add any additional documentation. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. The surveyor reviewed the above stated findings with Administrator and Clinical Manager. Findings include: According to the agency policy titled Medication List and Monitoring, dated 4/13/22, the agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient. The Registered Nurse will monitor medications for potential adverse effects and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. Agency nursing staff will assess on an ongoing basis the patient’s response to medication and the patient/caregiver compliance with the medication regimen. 1.Patient #3 had a start of care date of 2/4/25. Clinical record review revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25 identified the patient as having primary diagnosis of chromic leukemia and heart failure and physician orders for medications and treatments, with skilled nurse, physical and occupational therapy, and home health aide services. b. The start of care comprehensive assessment, dated 2/4/25, Staff F, Registered Nurse (RN), included documentation of drug interactions, side effects; but failed to identify duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 2. Patient #4 had a start of care date of 1/8/25. Clinical record review revealed: a. The POC, dated 1/8/25 to 3/8/25, identified the patient as having a diagnosis of hypertension and heart failure, physician orders for medications and treatments, with skilled nurse, physical and occupational therapy services. b. The start of care comprehensive assessment, dated 1/8/25, Staff F, RN, included documentation of drug interactions but failed to identify; side effects, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 3. Patient #5 had a start of care date of 08/22/24. Clinical record review revealed: a. The POC, dated 08/22/24 to 10/20/24, identified the patient as having a diagnosis of type 2 diabetes and Parkinson’s, physician orders for medications and treatments, with skilled nurse, physical and occupational therapy services. b. The start of care comprehensive assessment, dated 8/22/24, Staff G, RN , included documentation of drug interactions and side effects, but failed to identify, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. 4. Patient #1 had a start of care date of 1/1/21. Clinical record review revealed: a. Plan of Care, dated 12/22/24 to 2/19/25, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing and home health aide services and medications. b. Recertification comprehensive assessments, dated 8/19/24, 10/21/24 and 12/17/24, included documentation of drug interactions, side effects and duplicate medications; but failed to identify ineffective drug therapy and noncompliance with medications. The RN (registered nurse) failed to identify the required elements of the drug regimen review at the recertification comprehensive assessments. 5. Patient #2 had a start of care date of 1/21/25. Clinical record review revealed: a. Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing, physical therapy and occupational therapy services and medications. b. Start of Care comprehensive assessment, dated 1/21/25, included documentation of drug interactions, but failed to identify side effects, duplicate medications, ineffective drug therapy and noncompliance with medications. The RN failed to identify the required elements of the drug regimen review at the start pf care comprehensive assessment. 6. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus, interim physician orders for skilled nursing, physical therapy, occupational therapy and home health aide services and medications. b. Start of Care comprehensive assessment, dated 8/9/24, failed to include documentation a drug regimen review had been completed. During an interview on 2/12/25 at 2:38 PM, Clinical Manager reported she had reviewed the clinical record and the comprehensive assessment included documentation under the Medications section, medications reconciled and the question labeled M2001-Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?, was marked as No, No issues found during review. She reported this serves as the drug regimen review and when this question is marked No, the nurse is not able to add any additional documentation. The RN failed to identify the required elements of the drug regimen review at the start of care comprehensive assessment. The surveyor reviewed the above stated findings with Administrator and Clinical Manager.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on home observation visits, patient/staff interviews, clinical record review and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including the functional limitations, nutritional requirements, safety measures to protect against injury, and all supplies/equipment used by the patient for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #5, and #6). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to nor receive services, supplies and or treatments according to assessed needs and physician orders. 5. Patient #1 had a start of care date of 1/1/21. Clinical record review revealed the Plan of Care, dated 12/22/24 to 2/19/25, included a primary diagnosis of Type 2 Diabetes Mellitus and grab bars, tub/shower bench, walker, wheelchair, nebulizer as equipment and supplies the patient was using. During a home visit observation, on 2/10/25 at 1:20 PM, with Staff D, RN (registered nurse), the surveyor observed the patient siting in an electric lift chair, with 2 urinals on the floor next to the chair, a C-pap (continuous positive air pressure) mask and machine on the floor on the other side of the chair, a reacher on the cough, an electric power chair in the living room, a wheelchair cushion in the manual wheelchair and a medication planner. The patient reported using the electric power chair when leaving the home. The surveyor observed the patient using the reacher to pick up an item from the cough and hand to Staff D prior to Staff D filling the medication planner. The electric lift chair, urinal, C-pap masks and machine, reacher, electric power chair, wheelchair cushion and medication planner, failed to be included on the Plan of Care as equipment used by the patient. The Plan of Care failed to identify accurate equipment and supplies used by the patient. 6. Patient #2 had a start of care date of 1/21/25. Clinical record review revealed the Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for ketorolac ophthalmic solution and prednisolone acetate ophthalmic suspension, and grab bars, tub/shower bench, walker, wheelchair as equipment and supplies the patient was using. During a home visit observation, on 2/11/25 at 10:00 AM, with Staff E, COTA (certified occupational therapy assistant), the patient reported having a reacher that was used to assist with laundry and they did not have ketorolac ophthalmic solution and/or prednisolone acetate ophthalmic suspension and has never used these medications. The reacher failed to be included on the Plan of Care as equipment used by the patient and the ophthalmic medications were inaccurately added to the Plan of Care as medications used by the patient. The Plan of Care failed to identify accurate equipment, supplies and medications used by the patient. The surveyor reviewed the above stated findings with Administrator and Clinical Manager. Findings include: According to the policy titled Plan of Care, dated 4/13/22, the Plan of Care (POC) is developed in consultation with the staff, client, physician, and other providers involved in the clients care. The POC includes: diagnosis, allergies, homebound status if required, goals and outcomes to be achieved, mental status, functional limitations, activities permitted, safety measures to protect against injury, nutritional requirements, medications/treatments, procedures/treatments including amount, frequency and duration, supplies and equipment required, instructions and discharge plan, frequency/duration of visits, prognosis, rehabilitation potential and any other appropriate items such as precautions and contraindications. 1.Patient #3 had a start of care date of 2/4/25. Home observation and clinical record review revealed the following: a. The POC, dated 2/4/25 to 4/4/25, identified the patient had a primary diagnosis of chronic leukemia. The POC identified the following durable medical equipment (DME) used by the patient: grab bars, tub/shower bench, nebulizer, walker, toilet rails. b. During a home observation visit on 2/11/25 at 9 AM with Staff F, Registered Nurse (RN), the surveyor identified the following DME used by the patient: medication planner, a lift chair, and testing supplies for PT/INR (test that determines how long it takes for the blood to clot). During the same observation visit, patient stated the daughter had been assisting with the PT/INR testing routinely in the home. The agency failed to include all of the DME utilized by the patient on the POC. 2. Patient #4 had a start of care date of 1/8/25. Clinical record review revealed the following: a. The POC, dated 1/8/25 to 3/8/25, identified the patient had a primary diagnosis of hypertension and heart failure. The POC identified the only DME item used by the patient was a walker. b. The initial comprehensive assessment dated 1/8/2025, completed by Staff F, RN, included physicians orders for the skilled nurse to teach patient how to use oxygen safely in the home. c. The skilled nurse visit note, dated 1/13/25, completed by Staff F, RN, indicated the skilled nurse was filling a medication planner to assist the patient to take medications at appropriate times with correct dose. The agency failed to include all of the DME utilized by the patient on the POC. 3. Patient #5 had a start of care date of 11/10/22. Clinical record review revealed the following: a. The POC, dated 1/4/24 to 3/3/24, identified the patient had a primary diagnosis of type 2 diabetes with hyperglycemia (elevated blood sugars). The POC identified the DME being used by the patient as: grab bars, walker, elevated toilet seat, bedside commode, tub/shower bench and a wheelchair. b. The Initial comprehensive assessment dated 8/23/24, completed by Staff F, RN, identified a medication planner would be used to set up the patients medications on a routine basis. The agency failed to include all of the DME utilized by the patient on the POC. 4. Patient #6 had a start of care date of 7/1/24. Clinical record review revealed the following: a. The POC, dated 7/1/24 to 8/29/24, identified the patient had a primary diagnosis of left arm fracture and type 2 diabetes. The POC failed to address the following areas : mental/cognitive status, functional limitations, safety interventions to prevent injury, nutritional requirements, and activities either permitted or restricted. The agency failed to develop an accurate and completed POC at the start of care.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on home observations, staff and agency interviews, clinical record review and policy review, the agency failed to maintain a working Plan of Care for patients and update the working Plan of Cre with any new verbal/interim physician orders for 2 of 4 sampled patients (Patient #3 and #7) with interim physician orders Failure to update the Plan of Care increase the potential for medication errors in administration or in accurate provision and follow through with care. 2. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus and orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Interim physician order, dated 8/17/24, with an effective date of 8/17/24, for skilled nurse to perform wound care to abdominal wound daily. The clinical record lacked documentation of a Plan of Care update for the wound care to be provided daily. The surveyor reviewed the above stated findings with Staff A, Administrator, and Staff B, Clinical Manager. Findings include: According to agency policy titled Plan of Care, dated 4/13/22, identify modifications to the care plan are indicated by reassessments, patient condition , patient needs, changes in orders, and/or achievement of identified goals, and/or changes n visit sequencies. 1.Patient #3 had a start of care date of 2/4/25. Clinical record review revealed: a. The Plan of Care (POC), dated 2/4/25 to 4/4/25 identified a diagnosis of chronic leukemia and heart failure, with physician orders for medications and treatments with orders for skilled nurse, physical and occupational therapy, and home health aide services. The POC indicated the care giver would be monitoring and performing the PT/INR testing(a test that determines how fast the blood is clotting) on a weekly basis. b. An interim physician order, dated 2/4/25, directed the Registered Nurse (RN) to perform testing for PT/INR weekly with skilled nursing visit and to call the results into the coumadin clinic for dosing instructions. The agency failed to ensure the POC was updated to include all patient care orders.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on home visit observation and admission folder review, the agency failed to provide agency patients with visit schedule, including frequency of visit by agency personnel and personnel acting on behalf of the agency. The agency failed to provide this information for 1 of 2 sampled patients with home visits with admit folders in the home (Patient #2). Failure to provide the visit schedule left the patients at risk of not receiving the appropriate services as ordered. Findings include: Patient #2 had a start of care date of 1/21/25. Clinical record review revealed a Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for skilled nursing, physical therapy and occupational therapy services. During a home visit observation, on 2/11/25 at 10:00 AM, with Staff E, COTA (Certified Occupational Therapy Assistant), the surveyor reviewed the admission folder in the patient home. The folder failed to include a visit schedule. The agency failed to provide the patient and caregiver with a visit schedule. The findings were reviewed with Administrator and Clinical Manager.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on home visit observation and admission folder review, the agency failed to provide agency patients with written information on any treatments to be administered by agency personnel acting on behalf of the agency, including therapy services. The agency failed to provide this information for 1 of 2 sampled patients with home visits and therapy services (Patient #2). Failure to provide the patient with written information on treatments administered by the agency put the patient at risk for not receiving the ordered treatments including therapy services. Findings include: Patient #2 had a start of care date of 1/21/25. Clinical record review revealed a Plan of Care, dated 1/21/25 to 3/21/25, included a primary diagnosis of Type 2 Diabetes Mellitus and interim physician orders for skilled nursing, physical therapy and occupational therapy services. During a home visit observation, on 2/11/25 at 10:00 AM, with Staff E, COTA (Certified Occupational Therapy Assistant), the surveyor reviewed the admission folder in the patient home. The folder failed to identify any treatments to be administered by agency personnel and personnel acting on behalf of the agency, including therapy services. The agency failed to ensure the patient had written instructions outlining the treatments and services being provided. The findings were reviewed with Administrator and Clinical Manager.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to provide wound care as ordered by a physician for 1 of 1 sampled patients with wounds (Patient #7). Failure to ensure staff obtain physician orders for administration of services provided by agency staff, including wound care, placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care, dated 4/13/22, modifications to the care plan are indicated by reassessments, patient condition/needs, changes in orders are documented on discipline progress notes or physician verbal orders. Verbal orders will be signed and dated by the physician. Patient #7 had a start of care date of 8/9/24 and a discharge date of 9/17/24. Clinical record review revealed: a. Plan of Care, dated 8/9/24 to 10/7/24, included a primary diagnosis of Type 2 Diabetes Mellitus and orders for skilled nursing, physical therapy, occupational therapy and home health aide services. b. Interim physician order, dated 8/15/24, included documentation skilled nurse to provide wound care 5 days per week, per physician order, until wound closed. The order failed to identify what specific wound care should be provided. c. Skilled nursing visit, dated 8/16/24, included documentation a surgical wound central abdomen, measured 0.5 centimeters (cm) by 0.1 cm by 1 cm with tunneling of 3 cm at 12:00. Wound care performed using aseptic technique per physician order. d. Interim physician order, dated 8/17/24, with an effective date of 8/17/24, included documentation skilled nurse to perform wound care to abdominal wound, remove packing, cleanse wound, repack with quarter inch packing and cover with 4x4 gauze and secured with tape, using aseptic technique. Wound care daily. During an interview on 2/12/24 at 2:38 PM, Clinical Manager reported the nurse entered the incorrect start and effective date on the order, it should have been 8/15/24 instead of 8/17/24. Skilled nurse provided wound care without a physician order. The findings were reviewed with the Administrator and Clinical Manager.”